Supporting document Patient Details: Mrs. Miriam Gold, 85 years’ old Presenting Problems: Fluids overload (dialysis will be ceased due to palliative approach), Pneumonia & metastatic cervical cancer...

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Supporting document


Patient Details: Mrs. Miriam Gold, 85 years’ old


Presenting Problems: Fluids overload (dialysis will be ceased due to palliative approach),


Pneumonia & metastatic cervical cancer


History: COPD, GORD, CABGs


Cognitive: drowsy and vague


Social: lives home with husband. Patient and family want no further treatment


Diet: mild thick fluids (as tolerated)


Continence: incontinent, pad in situ


Mobility: RIB


Medications: patient is receiving medication via a syringe driver:


Fentanyl 200 mcg + Midazolam 10 mg (24/24


PRN medication: Fentanyl 25-50 mcg (S/C), Midazolam 2.5-5 mg (S/C)



Mrs. Gold was admitted to the ward for palliative treatment. Husband and children are not coping at home and she was in a lot of pain due to her malignant wound on her L) groin.


The malignant wound on her groin is purulent and it has developed a sinus. The odour coming out from the wound is offensive.


The patient requires pain relief before dressing change and for any pad changes/hygiene care. It was reported that her groin and peri-anal area is red due to bowel incontinence & discharge from her cervical cancer.


Mrs Gold is complaining of burning pain in her groin and perianal region.


Mrs Gold’s history notes state that she has developed a rectovaginal fistula as a result of the disease progress and radiotherapy.


Mrs gold also has a long-standing venous ulcer that is not healing.



You are required to write an individualised wound management plan for Mrs Gold.



Malignant fungating wound in groin.



Venous Ulcer



1. Holistic assessment of the patient that includes:


- medical history and examination of the patient and the wounds


- type of wounds with definition and the causes of wounds –example injury, fungal infection, micro-organism, viral


infection, disease.


- any investigation required for the wound


- wound management principles


- 4 potential common problems/complications of complex and challenging wounds.


2. Evaluation of each type of wound:


- wound bed status (include colour/s)


- wound characteristics


- wound measurements


- condition of surrounding skin (example- intact, breaking down)


- wound exudate colour, consistency, odour) - any further assessment required example doppler, wound swab.



3. Expectation of healing process for each type of wound; taking into consideration the wound and any factors that


may impact on the healing process-example, chronic health conditions, location of wound, infection, mobility, age, nutrition.



4. Wound management plan (for each type of wound), includes:


- moist wound healing


- skin & risk assessment


- wound cleansing


- pressure support and relieving devices


- prevention programs


- selection of wound dressing products (choose 1 product as a primary dressing for each wound).


- Secondary dressing (if required)


- pain management timeframes appropriate to wound care (if required)


- Referral for wound care expert assistance.



5. Health education for the patient regarding the wound. (ie. nutrition, elimination, mobility and any preventative


measures) in consultation with a registered Nurse.



6. Pain management relating to the wound in consultation with the RN prior to wound care including:


- medication/s accurately discussed


- frequency and dose


- justification for using a medication


- pain education for Mrs Gold



Marking criteria for each product document/s supplied.



1. Holistic assessment of the patient including:


-medical history and examination of the patient


and the wounds


-type of wounds with definition and the causes


of wounds –example, injury, fungal infection,


micro-organism, viral infection, disease.


-any investigation required for the wound


-wound management principles




Unsatisfactory


Holistic assessment of patient not included


Multiple errors in diagnosis (5+)




Satisfactory – Pass


Holistic assessment of patient provided.


Minor errors in diagnosis (2-4)


Three (3) of the required elements are missing or no


justification as to why it was not included OR


Two (2) errors in required elements


6 Marks




Credit


Holistic assessment accurately provided


Two (2) of the required elements are missing or no


justification as to why is was not included OR


One (1) error in a require element


8 Marks




Distinction


Holistic assessment accurately provided


One (1) required element not included or no


justification as to why it was not included (ie – this


resident has no other medical issues)


9 Marks




High Distinction


Holistic assessment of patient accurately provided


All required elements accurately included.


12 Marks






2. Evaluation of the wound including:


-Wound bed status (include colour/s)


-Wound characteristics


-Wound measurements


-Condition of surrounding skin (i.e. intact,


breaking down)


-Wound exudate (colour, consistency, odour)


-Any further assessment, Example-Doppler,


wound swab.




Unsatisfactory


No evaluation of wound provided or


Multiple errors in evaluation (5+)




Satisfactory – Pass


Evaluation of wound provided.


Minor errors in evaluation (2-4)


Three (3) of the required elements are missing or no


justification as to why it was not included OR


Two (2) errors in required elements


6 Mark




Credit


Accurate evaluation of wound provided


Two (2) of the required elements are missing or no


justification as to why is was not included OR


One (1) error in a require element


8 Marks





Distinction


Accurate evaluation of wound provided


One (1) required element not included or no


justification as to why it was not included (i.e. – there


is no wound exudate)


9 Marks




High Distinction


Accurate evaluation of wound provided


All required elements accurately provided


12 Marks


3. Expectation of healing process for each type of


wound, taking into consideration the wound and


any factors that may impact on the healing process


example: chronic health conditions, location of


wound, infection, mobility, age, nutrition.




Unsatisfactory –


Physiology of the healing process provided, four + (4)


errors in description


Type of wound not discussed


Factors that impact on healing not included




Satisfactory - Pass


Physiology of the healing process provided, three (3)


errors in description


Type of wound discussed, not linked back to wound


healing process


Any factors that may impact on the healing process of


chosen resident describe (1-2 errors) or reasons as to


why there are no factors that may impact on wound


healing provided


6 Marks









Credit


Physiology of the healing process provided, two (2)


errors in description


Type of wound discussed, not linked back to wound


healing process


Any factors that may impact on the healing process of


chosen resident accurately describe or reasons as to


why there are no factors that may impact on wound


healing provided


8 Marks




Distinction


Physiology of the healing process provided, one (1)


error in description


Type of wound discussed in relation to the healing


process


Any factors that may impact on the healing process of


chosen resident accurately describe or reasons as to


why there are no factors that may impact on wound


healing provided


9 Marks




High Distinction


Physiology of the healing process accurately describe


Type of wound discussed in relation to the healing


process


Any factors that may impact on the healing process of


chosen resident accurately describe or reasons as to


why there are no factors that may impact on wound


healing provided


12 Marks




4. Evaluation of the wound management plan


including:


-Moist wound healing


-Skin risk assessment


-Wound cleansing


-Pressure support & relieving device


-Prevention program


-Dressing product (primary dressing)


-Secondary dressing (if required)


-pain management timeframes appropriate


to wound care (if required)




Unsatisfactory –


Evaluation of the wound management plan described


with three + (3) errors


Three + (3) required element missing.




Satisfactory - Pass


Evaluation of the wound management plan described


with two (2) errors


Two (2) required element missing.


All provided elements accurately describe or reasons


as to why they have not been included provided (ie


there have been no changes to the wound management


plan during clinical placement)


12 Marks




Credit


Evaluation of the wound management plan described


with one (1) error


One (2) required element missing.


All provided elements accurately describe or reasons


as to why they have not been included provided (i.e.


there have been no changes to the wound management


plan during clinical placement)


16 Marks




Distinction


Evaluation of the wound management plan accurately


described


One (1) required element missing.


All provided elements accurately describe or reasons


as to why they have not been included provided (ie


there have been no changes to the wound management


plan during clinical placement)


18 Marks




High Distinction


Evaluation of the wound management plan accurately


described


All required elements accurately describe or reasons


as to why they have not been included provided (i.e.


there have been no changes to the wound management


plan during clinical placement)


24 Marks



5. Health education that may be provided to the


resident regarding their wound




Unsatisfactory –


Three + (3) errors in information provided




Satisfactory - Pass


Description of wound education provided with three (3)


errors


Wound education is relevant to chosen resident


6 Marks




Credit


Description of wound education provided with two (2)


errors


Wound education is relevant to chosen resident


8 Marks




Distinction


Description of wound education provided with one (1)


error


Wound education is relevant to chosen resident


9 Marks




High Distinction


Accurate description of wound education provided


Wound education is relevant to chosen resident


12 Marks



6. Pain management relating to the wound including:


-Medication/s accurately discussed


-Frequency and dose provided


-Justification for using particular


medication provided


-Patient’s education about pain


management




Unsatisfactory –


Pain management not appropriate for chosen resident ☐ ☐




Satisfactory - Pass


Pain management discussed


Three (3) required elements missing


6 Marks




Credit


Pain management discussed


Two (2) required elements missing


8 Marks




Distinction


Pain management discussed


One (1) required element missing


9 Marks




High Distinction


Pain management discussed


All required element accurately described


12 Marks

Answered Same DaySep 09, 2021HLTENN006Training.Gov.Au

Answer To: Supporting document Patient Details: Mrs. Miriam Gold, 85 years’ old Presenting Problems: Fluids...

Sunabh answered on Sep 11 2021
136 Votes
Running Head: NURSING        1
NURSING        2
NURSING
Table of Contents
1. Holistic Assessment of the Patient— Mrs. Gold    3
Medical History and Examination of Mrs. Gold as well as of the Wounds    3
Type of Wounds with Definition and Causes    3
Any Investigation Required for the Wound    4
Wound Management Principles    4
Four Potential Complications    4
3. Expectation of Healing Process for Each Type of Wound    4
References    6
1. Holistic Assessment of the Patient— Mrs. Gold
Medical History and Examination of Mrs. Gold as well as of the Wounds
Mrs. Gold was admitted to the hospital in for palliative care and the malignant wound on her groin area has become purulent along with the development of sinus. Further, it would be essential to consider that Mrs. Gold had been reported to suffer from many other complexities and wounds. Patient had a history of long-standing venous ulcer, which is not healing.
Further, patient’s history reflects that the malignant wound have developed into rectovaginal fistula due to disease progression and radiotherapy received as a treatment for metastatic cervical cancer. Upon wound examination, it was reported that the wound has developed wound sinus along with offensive odor. Further, patient’s groin area and peri-anal region is red due to loss of bowel control and discharge from cervical cancer; thus, not allowing the wound to dry and heal.
Type of Wounds with Definition and Causes
Two major wounds reported from the case study are ‘malignant fungating wound’ and ‘venous ulcers’. Malignant Fungating Wounds (MFWs) are resultant from cancerous cells, which upon invading the nearby skin and vessels enter the body (Tilley, Lipson & Ramos, 2016). The patient has been reported to suffer from metastatic cervical cancer and it can be considered as the major cause behind development of MFW.
On the other hand, Raffetto (2018) suggested that, venous ulcers are the...
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